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Interhospital Transfer of Critically Ill COVID-19 Patients: Preliminary Considerations From the Emilia-Romagna Experience

      Emilia-Romagna was 1 of the most affected Italian regions in terms of coronavirus disease 2019 (COVID-19) cases,
      • Sebastiani G
      • Massa M
      • Riboli E
      Covid-19 epidemic in Italy: evolution, projections and impact of government measures.
      and the whole health system had to undergo profound remodeling to face the emergency.
      • Zangrillo A
      • Beretta L
      • Silvani P
      • et al.
      Fast reshaping of intensive care unit facilities in a large metropolitan hospital in Milan, Italy: facing the COVID-19 pandemic emergency.
      In particular, the city area of Piacenza was quickly shown to be the most affected zone in Emilia-Romagna
      • Scarpioni R
      • Manini A
      • Valsania T
      • et al.
      Covid-19 and its impact on nephropathic patients: the experience at Ospedale “Guglielmo da Saliceto” in Piacenza.
      (Fig. 1), thus generating the nondeferrable necessity for a massive transfer of patients from congested wards and intensive care units (ICUs) of the western part of the region to other areas. Therefore, the regional task force for COVID-19 was set up in a few days and, among other tasks, has taken care, from the very beginning, of the transfer of infected patients between hospitals all over Emilia-Romagna (Fig. 1).
      Figure 1
      Figure 1Emilia-Romagna map showing the prevalence of COVID-19 in every Province and the number of patients transferred to the other receiving hospitals.
      Because of its central position and the presence of the regional emergency medical services dispatch center in Emilia Est
      • Semeraro F
      • Gamberini L
      • Tartaglione M
      • et al.
      An integrated response to the impact of coronavirus outbreak on the emergency medical services of Emilia Romagna.
      and a 24/7 helicopter emergency medical service (HEMS), Maggiore Hospital Carlo Alberto Pizzardi became the referral center for the retrieval of COVID-19 patients. On March 5, the retrieval missions, both via ground and using HEMS, started with the aim of supporting the hospitals in the Piacenza area, which were overburdened with incoming patients.
      As soon as the retrieval program started, a protocol was built in order to standardize these transports while granting adequate safety to staff
      • Wax RS
      • Christian MD
      Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients.
      and patients.
      This work has been based on the official guidelines of the Italian National Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care on the transport of critical patients,
      • Cabrini L
      • Caputo P
      • De Blasio E
      • et al.
      Trasferimenti Inter ed Intra Ospedalieri LG.
      and further consideration has been implemented in relation to our experiences of the first transports performed and the study of international literature, which is unfortunately still scarce at the moment.
      In the first phase (March 2020), the retrieval requests for COVID-19 patients were mostly related to ICU patients, whereas during the descending phase of the contagion (April 2020), several transfers were needed in order to unload standard care wards and allow their sanitization and restoration.

      Discussion

      Patient Retrieval Organization

      The regional task force receives calls from the sending hospitals (SHs) and takes care of contacting the receiving hospital (RH) to check the availability of ICU beds. Once availability is confirmed based on the patient's characteristics and the receiving ICU's capabilities, the regional task force decides which patients to transfer and where to send them (Fig. 1), so the on-call team is activated and the retrieval mission is then organized. Clinical information (Table 1) needs to be collected in order to check the feasibility and to plan the mission.
      Table 1Patient Inform ation to Collect Before Accepting the Mission
      Patient information to collect before starting mission (ABCDEFG list)
      Anamnesis and airwayPersonal and anthropometric data of the patient (possible need for bariatric stretcher)
      Anamnestic data
      Confirmation of swab positivity for SARS-CoV-2
      Airway assessment (spontaneous breathing, CPAP, NIV, orotracheal intubation, tracheostomy, difficult airway)
      Breathing and BGAVentilation modes and setting (VT/Pinsp, driving pressure, RR, PEEP, and FiO2)
      pH, pO2, pCO2, Lac, Hb, P/F ratio
      CirculationHemodynamic parameters (HR, IBP, and CVP if available)
      Drugs and drainagesSedation and paralysis
      Cardioactive and vasoactive drug infusion
      Drainage or other devices that require continuous suction
      Electrolytes and failuresOther organ failure that could affect transport safety (eg, acute renal failure with worsening hyperkalemia)
      GoodbyeNotification to family members of the incoming transfer (also verifiable on site)
      BGA = blood gas analysis; CVP = central venous pressure; Hb = hemoglobin; HR = heart rate; IBP = invasive blood pressure; FiO2 = fraction of inspired oxygen; Lac =Lactate; NIV = noninvasive ventilation; PEEP = positive end-expiratory pressure; pCO2 = partial pressure of carbon dioxide; P/F =partial pressure of oxygen (pO2) / fraction of inspired oxygen (FiO2) Ratio; pO2 = partial pressure of oxygen; RR = respiratory rate; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; VT/Pinsp = Tidal Volume/inspiratory pressure.
      COVID-19 patients are often highly complex ICU patients with more than 1 system failure; therefore, the choice of the patient to send and the vehicle adopted is fundamental. Absolute and relative contraindications to transfer are summarized in Table 2
      • Duan J
      • Han X
      • Bai L
      • Zhou L
      • Huang S
      Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients.
      Extracorporeal Life Support Organization
      Guidelines for adult respiratory failure.
      • Markakis C
      • Dalezios M
      • Chatzicostas C
      • Chalkiadaki A
      • Politi K
      • Agouridakis PJ
      Evaluation of a risk score for interhospital transport of critically ill patients.
      • DellaVolpe JD
      • Lovett J
      • Martin‐Gill C
      • Guyette FX
      Transport of mechanically ventilated patients in the prone position.
      ; it is important to note that stricter criteria were adopted for the use of HEMS transfer because of higher technical complexity of emergency interventions during flight. However, the final decision about the appropriateness of the transfer and the eventual measures to take before transfer were up to the physician responsible for the transfer.
      Table 2Contraindications to the Transfer of Coronavirus Disease 2019 Patients
      RelativeAbsolute
      CPAP or NIV support with HACOR score > 5Patients who meet ECMO criteria without ECMO team available
      Severe obesity (bariatric stretcher available)large undrained pneumothorax
      Severe electrolyte disordersSevere hemodynamic instability with impending risk of cardiac arrest
      Risk score for transport patients ≥ 8Futility (extremely poor short-term prognosis)
      Need to continue pronation cycleImpending need for emergency procedures (surgery, catheterization laboratory, etc)
      Patient or relatives opposed to transfer
      CPAP = continuous positive airway pressure; ECMO = extracorporeal membrane oxygenation; HACOR = Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate Score; NIV = noninvasive ventilation.

      Retrieval Team

      The composition of the retrieval team was related to the needs of the patients transported; however, for patients needing continuous positive airway pressure or noninvasive

      Arulkumaran N, Brealey D, Howell D, Singer M. Use of non-invasive ventilation for patients with COVID-19: a cause for concern? Lancet Respir Med. https://doi.org/10.1016/S2213-2600(20)30181-8. Published Online April 20, 2020.

      or invasive ventilation, the team had to include an anesthesiologist/intensivist,
      • Yang M
      • Dong H
      • Lu Z
      Role of anaesthesiologists during the COVID-19 outbreak in China.
      a critical care nurse, and a professional ambulance driver in order to grant adequate management in case of complications occurring during the transfer.

      Vehicles

      The ambulances involved in these missions could belong to the EMS of the RH or the SH, and the transport personnel could be brought to the SH via ground or air. (For air missions, see the COVID-19 HEMS Retrieval Program section). Due to the complexity of these patients, there were difficulties in terms of movement while wearing personal protective equipment (PPE), and, in order to reduce the risk of contamination, the ambulances were functionally divided into a clean zone (the driver cabin) and a contaminated zone (the patient cabin) as shown in Figure 2. The latter was further divided into 2 areas, an area dedicated to airway management and breathing supervised by the attending doctor and an area dedicated to monitoring and infusions, which was functionally supervised by the attending nurse.

      Equipment

      The personnel directly involved in the management of the infected patient (doctor and nurse) wore an FFP2 mask, gowns, gloves, and eye protection, whereas the driver not directly involved in patient management did not have to wear any protections as per World Health Organization recommendations.
      World Health Organization
      Rational use of personal protective equipment for coronavirus disease (COVID-19): interim guidance.
      In addition to basic ambulance equipment involving a mechanical ventilator, monitor/defibrillator, infusion pumps (at least 2), a portable suction unit, and a backpack carrying basic and advanced airway management devices and emergency drugs, premade kits containing all the necessary PPEs and quick kits (Fig. 3) for the management of airway management and monitoring problems were added. The last 2 are inside a hard-shell box that grants rapid access to both airway devices and drugs most frequently used for emergencies without the need to open the standard backpack, allowing a reduction of material needing sanification at the end of the mission.
      Figure 3
      Figure 3Scheme of the ‘Quick Kits’ in the hard-shell box.

      Transport

      The drivers must always stay more than 1 meter away from both the patient and other personnel, keep the front cabin closed, store any clean materials (eg, retrieval team sweatshirts and personal belongings), communicate with the dispatch center to confirm departure, and estimate the time of arrival at the RH. Considering the difficulty of moving around in the sanitary compartment with protection, it is suggested to simplify the required equipment by minimizing the number of infusions, giving priority to sedative and vasoactive drugs, opiates, and muscle relaxants that can be administered by boluses.
      Another aspect to take into consideration is the high level of alertness with respect to airway management. It is advisable not to postpone intubation in case of suspicion and, in case of accidental extubation, to use a device for difficult airway management in the first instance.
      • Cook TM
      • El-Boghdadly K
      • McGuire B
      • McNarry AF
      • Patel A
      • Higgs A
      Consensus guidelines for managing the airway in patients with COVID-19.
      Patient records must be transported and delivered in a bag to keep them clean. Once the patient has been delivered to the RH, all team material must be recovered by collecting all the cables in a bag. The retrieval team gets on the ambulance and goes to the decontamination area still wearing all the PPE.

      Transport of Multiple Patients With Noninvasive Ventilation

      In this case, an experienced ICU doctor has assessed all patients according to their clinical condition (Table 3) and care needs and assigned each one an appropriate type of team and an RH. Because of the high risk of deterioration and need of emergency endotracheal intubation, we decided to keep ambulances with the same destination in line to take advantage of mutual support. Moreover, an additional car followed the group with spare material and a senior consultant on standby to get into ambulances if needed. A dedicated radio channel was used to communicate in the ambulance group.
      Table 3Clinical Evaluation for Impending Worsening Risk Before Transport
      Airway and Breathing AssessmentImpending Worsening Signs
      Spontaneous breathing:

      Nasal cannula

      Venturi mask

      Nonrebreather mask

      HFNC
      RR > 30
      Accessory muscle use
      Abdominal breathing
      NIV/CPAPHACOR ccore > 5
      pCO2 > 50 mm Hg or < 30 mm Hg
      Invasive ventilation

      ETT

      Tracheostomy
      pO2 < 60 mm Hg and/or SpO2 < 90%

      despite FiO2 > 0.6
      Hemodynamic instability
      MOF
      CPAP = continuous positive airway pressure; ETT = endotracheal tube; FiO2 = fraction of inspired oxygen; HACOR =Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate Score; HFNC = high-flow nasal cannula; MOF = multiorgan failure; NIV = noninvasive ventilation; RR = respiratory rate; pCO2 = partial pressure of carbon dioxide; pO2 = partial pressure of oxygen; SpO2 = oxygen saturation.

      Decontamination Plan

      Since COVID-19 inter- and intrahospital transport started, a decontamination area was instituted at the ambulance home base. Afterward, because of the increase in transport demand and the concomitant start of the COVID-19 HEMS retrieval program, it was necessary to establish a larger and more equipped decontamination area close to the hospital.
      The vehicle (ambulance or helicopter) is sanitized by dedicated personnel, all surfaces are thoroughly cleaned with alcohol-based products, and all medical devices are disinfected with chlorhexidine wipes or hydrogen peroxide and then put in a decontamination cell for ozonation. Showers and clean uniforms are available on site. Every 15 days the aircraft can be sanitized with the ozone machine. The entire process should last less than 45 minutes for an ambulance and 1 hour for the helicopter.

      COVID-19 HEMS Retrieval Program

      In agreement with the regional task force and emergency dispatch center, the retrieval may be performed entirely by HEMS. Maggiore Hospital HEMS is on duty 24/7 as reported earlier, and, after the outbreak began, a panel barrier was installed inside the helicopter to separate the sanitary compartment from the cockpit to protect pilots.
      In view of the increased complexity due to air transport, the criteria for patient selection are necessarily stricter than for ground transport. Patients with relative contraindications reported in Table 1 are not eligible for HEMS. Risk Score for Transport Patients ≥ 8 should be evaluated on a case-by-case basis. The retrieval team and equipment are the same as for ground transport.
      In case of landing on the roof helipad that can be reached directly from the ICU without the need for an ambulance, it is advisable to unload the patient from the helicopter directly onto the ICU bed in order to minimize movements and the consequent risk of disconnection of the respiratory circuit. After patient discharge, HEMS take off, heading to the decontamination area where the aircraft is sanitized with a process analog to that used for ambulances.

      Activity Report

      From March 5, 2020, to April 21, 2020, 159 patients were transferred from the Piacenza area to other regional ICUs or medium care units; of these, 139 were ICU patients undergoing invasive ventilation, and 20 patients were undergoing noninvasive ventilation or continuous positive airway pressure. In addition, we carried out 29 interhospital transports between hospitals in the Bologna area. In one third of the missions, the team was brought to the site by helicopter; this allowed a significant reduction in total mission time, from a median of 6 hours for transports totally managed with ambulances to 4 hours 30 minutes. Moreover, in several cases, more teams were brought by helicopter to optimize the logistics of multiple transfers. So far, we performed only 1 mission entirely with HEMS. During these transfers, we had 2 nonfatal events and no fatal events. One was due to ventilator failure and was managed with a quick switch to bag valve ventilation with transient desaturation, and the second one was a sudden worsening of hemodynamics caused by the onset of supraventricular tachycardia managed with drugs.
      The most frequent complication was transient desaturation. In nearly 25% of cases, oxygen saturation below 90% was not correctable during the transfer but did not lead to death. One third of the patients needed noradrenaline infusion during transport; this is probably related to the fact that several patients were transported shortly after being intubated in the emergency room because of the unavailability of ICU beds. The rapid induction probably induced hypotension in these patients who showed fluidic depletion due to persistent fever in the previous days. No critical events concerning the risk of contamination of personnel have been reported.

      Conclusions

      When an epidemic outbreak puts in crisis the surge capacity of a hospital,
      • Zhang S
      • Wang Z
      • Chang R
      • et al.
      COVID-19 containment: China provides important lessons for global response.
      the redistribution of critically ill patients is an accepted strategy
      • Sheikhbardsiri H
      • Raeisi AR
      • Nekoei-Moghadam M
      • Rezaei F
      Surge capacity of hospitals in emergencies and disasters with a preparedness approach: a systematic review.
      to unload the ICUs and maintain a high quality of care. In our case, the need to transport many patients in a short time required rapid standardization of procedures to minimize risks, and all the staff involved gave satisfactory feedback.
      Although further studies are needed to highlight any detrimental effects of transport among this type of patient, it must be considered that in many cases at the time of transport, it was not possible to offer adequate treatment to patients at the SH. Major concerns are raised against the risk of spreading the infection

      Nacoti M, Ciocca A, Giupponi A, et al. At the epicenter of the Covid-19 pandemic and humanitarian crises in Italy: changing perspectives on preparation and mitigation. NEJM Catal. doi:10.1056/CAT.20.0080, Accessed March 21, 2020.

      and reducing available beds in case of a sudden increase in patients in the RH too. This possibility has been averted thanks to strict social and health prevention measures as well as the implementation of dedicated hospital pathways and the increase in ICU beds. Interhospital transfers of infected patients, even the critically ill, during an epidemic outbreak are feasible and help to maintain a high level of care thanks to a fairer distribution of resources.

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